Helping Hands: Osteopathic Treatment for LBP of Pregnancy
Abstract & Commentary
By Russell H. Greenfield, MD, Editor
Synopsis: Osteopathic manipulative treatment (OMT) is one of a number of CAM therapies often considered for the treatment of third trimester lower back pain (LBP). Results of this small trial suggest that manual therapy during late pregnancy may help improve back-specific functioning but has little impact on back pain. While OMT may be appropriate for some pregnant women experiencing LBP, unless the obstetrician is a DO such care requires additional appointments, and ultimately still may not offer significant pain relief.
Source: Licciardone JC, et al. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: A randomized controlled trial. Am J Obstet Gynecol 2010; 202:43.e1-8.
This phase ii randomized, placebo-controlled intervention trial was conducted through The Osteopathic Research Center at the University of North Texas Health Science Center. The researchers were interested in examining the effects of osteopathic manipulative treatment (OMT) on back pain occurring in the third trimester of pregnancy, as well as associated symptoms and related physical functioning.
Obstetric clinic patients were screened up to the 30th week of pregnancy for eligibility and willingness to participate in the study, with all subjects enrolled between the 28th and 30th weeks gestation. Subjects were then randomized to one of three treatment groups: conventional prenatal care with OMT (C+OMT); conventional prenatal care with sham ultrasound treatment (C+SUT); or conventional prenatal care only (C). Participants were stratified by age and gravid status into four groups: age ≤ 24 years and primigravida, age ≤ 24 years and multigravida, age ≥ 25 years and primigravida, age ≥ 25 years and multigravida. Blocks of 6 subjects were used to randomly assign two subjects to each of the three treatment groups within each age- and gravid-specific stratum. Treatments of 30 minutes' duration were to be administered at seven successive visits by licensed faculty (weeks 30, 32, 34, 36, 37, 38, and 39). A standardized OMT protocol was used that permitted identification and treatment of specific areas of somatic dysfunction. Any of the following treatment modalities could be employed: soft tissue, myofascial release, muscle energy, and range-of-motion mobilization.
Data were collected by research personnel blind to therapy and included information on back pain measured using an 11-point scale, and back-specific functioning as measured by the Roland-Morris Disability Questionnaire (RMDQ). Intention-to-treat analysis was employed.
A total of 49, 48, and 49 subjects were randomly assigned to the three groups, respectively. Two subjects were lost to follow-up, both prior to first visit, so the intention-to-treat analysis included data on 144 women. Completion percentages from highest to lowest were: C > C+OMT > C+SUT. Four women missed more than 50% of their scheduled appointments, two each in the C+OMT and C+SUT groups. Before visit 7 a total of 67 subjects were either withdrawn from the study (development of high-risk condition, n = 7) or censored due to delivery (n = 60).
Pain levels between the groups were similar at the outset. By study's end, however, non-statistically significant differences were evident between the groups, with mean pain levels dropping in the C+OMT group, remaining stable in the C+SUT group, and increasing in the C group. RMDQ scores increased significantly over time, representing decreased back-related functionality, but less so in the C+OMT group than in the other two groups. No adverse effects of treatment were noted. The authors concluded that OMT as a complement to conventional obstetric care slows or halts the worsening of back-specific functioning during the third trimester of pregnancy.
The development of LBP during the late stages of pregnancy remains a significant health issue that impacts an estimated 25% of all expectant mothers. Physicians and patients alike are reticent to use pain medication for obvious reasons so conservative approaches are the norm, but they are not always fully effective. This reality prompts many women to explore complementary approaches such as acupuncture, massage therapy, mind/body interventions, and pregnancy yoga. OMT is a form of manual therapy that often comes up in such discussions not only because of its perceived potential clinical benefit, but also because it is offered by licensed physicians.
Osteopaths focus not only on the structural body changes inherent in pregnancy, such as an increased pelvic tilt, but also fluid and hormonal shifts. For example, the increased ligamentous laxity typically seen during pregnancy usually precludes use of high velocity, low amplitude manipulative techniques (think "cracking") due to theoretical risks.
In the current study the treating physicians followed a standardized OMT protocol or applied sham ultrasound therapy, the latter using machines modified to provide convincing sights and sounds associated with fully operational ultrasound equipment. By the end of the trial it was shown that back-specific functioning appeared to improve most when OMT was added to conventional care, but there was not a statistically significant associated improvement in back pain with OMT. This finding could be related to the small sample size or to faulty randomization as noted by the authors, but it weakens the argument for OMT in this setting. Another concern is the need for multiple additional medical appointments to meet with an osteopath, much the same if a patient were to seek massage therapy or acupuncture, unless the woman is fortunate enough to have a DO as her obstetrician. This paper underscores the possibility that OMT may help in the treatment of LBP in late pregnancy, but it also points out potentially significant limitations of OMT in this setting.